A prescribing incentive scheme for non-fundholding general practices: an observational study.

OBJECTIVE: To examine the effects of a financial incentive scheme on prescribing in non-fundholding general practices. DESIGN: Observational study. SETTING: Non-fundholding general practices in former Northern region in 1993-4. INTERVENTION: Target savings were set for each group of practices; those that achieved them were paid a portion of the savings. MAIN OUTCOME MEASURES: Financial performance; prescribing patterns in major therapeutic groups and some specific therapeutic areas; rates of generic prescribing; and performance against a measure of prescribing quality. SUBJECTS: 459 non-fundholding general practices, grouped into three bands according to the ratio of their indicative prescribing amount to the local average (band A > or = 10% above average, B between average and 10% above, C below average). RESULTS: 102 (23%) of 442 practices achieved their target savings (18%, 19%, and 27% of bands A, B, and C respectively). Band C practices that achieved their target had a lower per capita prescribing frequency for gastrointestinal drugs, inhaled steroids, antidepressants, and hormone replacement therapy. There were no other significant differences in prescribing frequency, and no reduction in the quality of prescribing in achieving practices. Total savings of pounds 1.54 m on indicative prescribing amounts were achieved. Payments from the incentive scheme and discretionary quality awards resulted in pounds 463,000 being returned to practices for investment in primary care. CONCLUSIONS: The prescribing behaviour of non-fundholding general practitioners responded to financial incentives in a similar way to that of fundholding practitioners. The incentive scheme did not seem to reduce the quality of prescribing.     

Punishment of Minor Female Genital Ritual Procedures: Is the Perfect the Enemy of the Good?

Female genital alteration (FGA) is any cutting, removal or destruction of any part of the external female genitalia. Various FGA practices are common throughout the world. While most frequent in Africa and Asia, transglobal migration has brought ritual FGA to Western nations. All forms of FGA are generally considered undesirable for medical and ethical reasons when performed on minors. One ritual FGA procedure is the vulvar nick (VN). This is a small laceration to the vulva that does not cause morphological changes. Besides being performed as a primary ritual procedure it has been proposed as a substitute for more extensive forms of FGA. Measures advocated or taken to reduce the burden of FGA can be punitive or non‐punitive. Even if it is unethical to perform VN, we argue that it also is unethical to attempt to suppress it through punishment. First, punishment of VN is likely to cause more harm than good overall, even to those ostensibly being protected. Second, punishment is likely to exceed legitimate retributive ends. We do not argue in favor of performing VN. Rather, we argue that non‐punitive strategies such as education and harm reduction should be employed.     

How the Tiwi Construct the Deceased’s Postself in Mortuary Ritual

ABSTRACT

In this paper I will discuss Tiwi mortuary rites as a transformative, relational process in which the deceased’s postself is created. The deceased’s self is fashioned and manifested after death through a series of ritual practices performed by specific relatives. This approach allows me not only to stress the concern Tiwi people show about being remembered after death but also how this concern defines each participant’s ceremonial role and constitutes one of the mortuary ritual’s major aims. The deceased will be remembered as portrayed in the final rites.     

Notes about the uses of plants by one of the last healers in the Basilicata Region (South Italy)

ABSTRACT: BACKGROUND: The paper refers to the knowledge and uses of plants and to the linked ritual practices as referred by Matteo (It.'Zi Matteo', En. 'Uncle Matthew'), one of the last elder healers in the Basilicata Region (South Italy). Particular attention is also paid to the uses of 'Vruca' (Tamarix gallica L.) as a medicinal and magical plant used to heal common warts on various parts of the body. METHODS: After obtaining prior informed consent, we collected data through an open interview about the uses of the plants and on the associated ritual practices. For each species, data were collected that included the vernacular names, preparation, plant parts utilized and their method of use. RESULTS: The uses of 52 taxa are described. Among these, 43 are or were employed medicinally, eight as culinary foodstuffs, and 4 for domestic, handicraft or ethnoveterinary uses. Among the major findings: the ritual and magical use of Tamarix gallica L. to heal warts is described in detail; so far, no records of similar use were found in any Italian ethnobotanical studies conducted in southern Italy. CONCLUSION: Phytotherapy in the Basilicata region is practiced by elderly people who resort to medicinal plants for mild illnesses; we interviewed one of those traditional healers who is very experienced in the field, and possesses rich ethno-pharmacological knowledge.     

Reinscribing the birthing body: homebirth as ritual performance

In this article, I examine the clinical practices engaged in by U.S. homebirth midwives and their clients from the beginning of pregnancy through to the immediate postpartum period, deconstructing them for their symbolic and ritual content. Using data collected from open-ended, semistructured interviews and intensive participant-observation, I describe the roles ritual plays in the construction, performance, and maintenance of birth at home as a transgressive rite of passage. As midwives ritually elaborate approaches to care to capitalize on their semiotic power to transmit a set of counterhegemonic values to participants, they are attempting, quite self-consciously, to peel away the fictions of medicalized birthing care. Their goal: to expose strong and capable women who "grow" and birth babies outside the regulatory and self-regulatory processes naturalized by modern, technocratic obstetrics. Homebirth practices are, thus, not simply evidence-based care strategies. They are intentionally manipulated rituals of technocratic subversion designed to reinscribe pregnant bodies and to reterritorialize childbirth spaces (home) and authorities (midwives and mothers).     

Disciplining Investment Bankers, Disciplining the Economy: Wall Street's Institutional Culture of Crisis and the Downsizing of "Corporate America"

ABSTRACT   Countering the "mystique" of finance as abstract and disembedding, in this article I approach the financial market from the site of investment banking corporate culture to concretize large-scale processes and access its effects in the world. By investigating Wall Street investment banks' role in two pivotal socioeconomic phenomena—rampant downsizings throughout "corporate America" and the financial bubble and bust of 2001—I explore whether financial crises and corporate downsizing can be better understood via Wall Street's quotidian practices. I draw theoretical inspiration from the figure of the downsized investment banker, who embodies and connects Wall Street's rationales for downsizing as well as "the effects." Although shareholder value and externalized market justifications are Wall Street's models for understanding downsizing, I move beyond these dominant assumptions, demonstrating that bankers' own work experiences, market temporalities, and organizational culture serve as an incisive model to explain Wall Street's role in downsizing and financial crisis. [Keywords: Wall Street, corporate downsizing, financial markets, shareholder value, organizational culture]     

Consequences of wooded shrine rituals on vegetation conservation in West Africa: a case study from the Bwaba cultural area (West Burkina Faso)

Anthropological contributions that challenge several common perceptions on sacred sites are still poorly taken into account in conservation and ecological studies. This paper aims at filling this gap and providing a better framework for biological studies. Local concepts of natural sacred sites and their ritual administration were studied and the ritual practices relating to the vegetation of these sites were analyzed in the Bwaba cultural area in West Burkina Faso. Our research shows that these ritual practices are much more diverse and fluid than might have been supposed. Protection ‘by tradition’ is thus rather different from what we call conservation. While vegetation does matter, its presence on sacred sites is not essential. In addition, under certain circumstances, sacred sites may be transferred or reproduced elsewhere. Attention is drawn to the inadequacy of ‘sacred woods’ as a category, in an ecological as well as an anthropological sense. Even if wooded shrines may contribute to biodiversity conservation as a side-effect of their religious purpose, the idea that they fundamentally are ‘endogenous’ nature conservatories must be disproved.     

Violence,solace, and ritual: A case study from Island Southeast Asia

Most headhunting traditions in island Southeast Asia link ritual violence to grief and mourning. Some of the more persuasive analyses of these practices pivot on notions of rage and catharsis, arguing that turbulent emotions motivate persons to take up cleansing acts of violence. This paper seeks a more complex understanding of how ritual may connect bereavement and violence through a look at case materials from highland Sulawesi (Indonesia). Ritual practices there suggestthat the resolution of communal mourning is more significant than personal catharsis in motivating violence; that individual affect is refigured collectively as political affect; and that varied discursive forms, such as vows, songs, and noise mediate the ways in which people put grief behind them and resume their lives. Indeed, such discursive forms appear to be generative sites for violence and solace.     

Social inequality and signaling in a costly ritual

Evolutionary perspectives suggest that participation in collective rituals may serve important communicative functions by signaling practitioners' commitment to the community and its values. While previous research has examined the effects of ritual signals at the individual and collective level, there has been limited attention directed to the impact of socio-environmental factors on the quality of ritual signaling. We examined this impact in the context of the Thaipusam Kavadi, a collective ritual performed by Tamil Hindus worldwide that involves body piercings and other costly activities. We show that participants' relative position in the social hierarchy systematically affects the form of ritual signaling. Specifically, we found that low-status participants are more likely to engage in signaling modalities that require somatic and opportunity costs in the form of body piercings and cumulative effort, while high-status individuals are more likely to use financial capital, in the form of more elaborate material offerings to the deity. Moreover, signaling in each particular modality is stronger among individuals who participate in more public (but not private) rituals, corresponding to their long-term commitment to the community. In sum, our results demonstrate that social hierarchies exact unequal requirements on ritual participants, who in turn modify their signaling strategies accordingly.     

Tailoring an intervention to the context and system redesign related to the intervention: A case study of implementing shared medical appointments for diabetes

Background

Health care organizations exert significant influence on the manner in which clinicians practice and the processes and outcomes of care that patients experience. A greater understanding of the organizational milieu into which innovations will be introduced, as well as the organizational factors that are likely to foster or hinder the adoption and use of new technologies, care arrangements and quality improvement (QI) strategies are central to the effective implementation of research into practice. Unfortunately, much implementation research seems to not recognize or adequately address the influence and importance of organizations. Using examples from the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI), we describe the role of organizational research in advancing the implementation of evidence-based practice into routine care settings.

Methods

Using the six-step QUERI process as a foundation, we present an organizational research framework designed to improve and accelerate the implementation of evidence-based practice into routine care. Specific QUERI-related organizational research applications are reviewed, with discussion of the measures and methods used to apply them. We describe these applications in the context of a continuum of organizational research activities to be conducted before, during and after implementation.

Results

Since QUERI's inception, various approaches to organizational research have been employed to foster progress through QUERI's six-step process. We report on how explicit integration of the evaluation of organizational factors into QUERI planning has informed the design of more effective care delivery system interventions and enabled their improved "fit" to individual VA facilities or practices. We examine the value and challenges in conducting organizational research, and briefly describe the contributions of organizational theory and environmental context to the research framework.

Conclusion

Understanding the organizational context of delivering evidence-based practice is a critical adjunct to efforts to systematically improve quality. Given the size and diversity of VA practices, coupled with unique organizational data sources, QUERI is well-positioned to make valuable contributions to the field of implementation science. More explicit accommodation of organizational inquiry into implementation research agendas has helped QUERI researchers to better frame and extend their work as they move toward regional and national spread activities.     

Feasting, Craft Specialization, and the Ritual Mode of Production in Small-Scale Societies

Economic intensification has been documented in a diversity of small-scale societies. The existing archaeological theory concerning such intensification has tended to privilege economic and political explanations and largely ignores social action and ritual performance as motivations for economic change. In this article, 1 use both ethnographic and archaeological data to argue that ceremonial feasting and the need for socially valued goods, which are critical for ritual performance and necessary for a variety of social transactions, create the demand that underwrites and sustains economic intensification in small-scale societies. Food for large-scale feasts is acquired through the intensification of food production and procurement targeted specifically for feasting, rather than from the surplus available from routine subsistence production. Large-scale demands for socially valued goods tend to result in specialization on the production of "extraordinary" material culture, which is characterized by two modes of circulation, in networks of social obligations or as offerings in sacred locations. [Key words.craft specialization, exchange, feasting, ritual]     

Informal Trade,Contrabando and Prosperous Socialities in Arequipa,Peru

The article explores trading activities at an outdoor market in the city of Arequipa, Peru, with the intention of discussing how notions of ‘the market’ are negotiated in terms of moralities. More specifically, it seeks to address the way in which the moralities of ‘the market’ are made the object of negotiation in a context where trade is of a more or less informal kind. In particular, the article describes the practices of smuggling (contrabando) across the border with Bolivia, an issue that has been only briefly discussed in the literature on the Andes. The argument is that the practices of petty trade and ‘informality’, ritual payments and brujería (harmful acts, or witchcraft) in the market context should not necessarily or exclusively be seen in terms of resistance as is often suggested. Instead, these practices should be seen in terms of Andean notions of reciprocity and circulation as significant for the establishment and maintenance of prosperity, that is, prosperity understood as relationally created.     

"It's at a Time in Your Life When You Are Most Vulnerable": A Qualitative Exploration of the Financial Impact of a Cancer Diagnosis and Implications for Financial Protection in Health

Although cancer patients may incur a wide range of cancer-related out-of-pocket costs and experience reduced income, the consequences of this financial burden are poorly understood. We investigated: financial adjustments needed to cope with the cancer-related financial burden; financial distress (defined as a reaction to the state of personal finances); and factors that increase risk of financial difficulties. Two sets of semi-structured face-to-face interviews were conducted with 20 patients with breast, lung and prostate cancer and 21 hospital-based oncology social workers (OSWs) in Ireland, which has a mixed public-private healthcare system. Participants were asked about: strategies to cope with the cancer-related financial burden; the impact of the financial burden on the family budget, other aspects of daily life, and wellbeing. OSWs were also asked about patient groups they thought were more likely to experience financial difficulties. The two interview sets were analysed separately using a thematic approach. Financial adjustments included: using savings; borrowing money; relying on family and friends for direct and indirect financial help; and cutting back on household spending. Financial distress was common. Financial difficulties were more likely for patients who were older or younger, working at diagnosis, lacked social support, had dependent children, had low income or had few savings. These issues often interacted with one another. As has been seen in predominantly publically and predominantly privately-funded healthcare settings, a complex mixed public-private healthcare system does not always provide adequate financial protection post-cancer. Our findings highlight the need for a broader set of metrics to measure the financial impact of cancer (and to assess financial protection in health more generally); these should include: out-of-pocket direct medical and non-medical costs; changes in income; financial adjustments (including financial coping strategies and household consumption patterns); and financial distress. In the interim, cancer patients require financial information and advice intermittently post diagnosis.     

Syncretic Persons: Sociality,Agency and Personhood in Recent Charismatic Ritual Practices among North Mekeo (PNG)

This paper explores the syncretic accommodations made by North Mekeo (PNG) villagers arising from recent historical encounters with Catholic (Sacred Heart) missionaries over issues of ritual authenticity and effectiveness, personhood, and agency in a wider field of Christian evangelism and globalisation. Through a careful examination and comparison of pre‐existing ritual notions and practices (e.g., sorcery techniques, mortuary ritual performance, gender rituals) and the recent trends of commodification and enthusiastic Catholic charismatic performance, what might appear to be incongruous religious beliefs and practices are shown to possess numerous remarkably compatible similarities at the level of explicit cultural categorisation and ritual enactment. In accord with long‐standing anthropological arguments, recent North Mekeo syncretism thus consists of an integrated, albeit transformed rather than ‘confused’, mixing of indigenous and exogenous religious elements. Further, in this analysis of recent Melanesian religious change syncretism implies a novel conceptual convergence between syncretic processes and the dynamics of personhood, sociality and agency as construed in the framework of the ‘new Melanesian ethnography’.     

Financial Relationships between Organizations That Produce Clinical Practice Guidelines and the Biomedical Industry: A Cross-Sectional Study

BackgroundFinancial relationships between organizations that produce clinical practice guidelines and biomedical companies are vulnerable to conflicts of interest. We sought to determine whether organizations that produce clinical practice guidelines have financial relationships with biomedical companies and whether there are associations between organizations’ conflict of interest policies and recommendations and disclosures provided in guidelines.ConclusionsFinancial relationships between organizations that produce clinical practice guidelines and biomedical companies are common and infrequently disclosed in guidelines. Our study highlights the need for an effective policy to manage organizational conflicts of interest and disclosure of financial relationships.     

The Materiality of Relational Transformations: Propositions for Renewed Analyses of Life-Cycle Rituals in Melanesia and Australia

ABSTRACT

This paper introduces this special issue and analyses Papua New Guinea and Australian initiation and death rituals as moments of relational transformations. Although the general argument is not completely new, it has often remained an undemonstrated statement. The paper hence focuses on the specific ways people make these changes effective and express them in their rituals. It is suggested that an invariant modus operandi is in play in which, for a relation to be transformed, its previous state must first be ritually enacted. Towards the end of the ritual, the new state of the relationship is itself publicly enacted through a manifestation of the form the relation takes after the ritual. The paper suggests that a relationship cannot be transformed in the absence of the persons concerned. The relational components need to be either directly present, such as in initiations, or mediated through objects, such as in death rituals.     

The high cost of half-hearted breastfeeding promotion in Germany

The economic value of breastfeeding to the society at large is under researched and its importance as a preventive public health strategy is underestimated. What little research there is indicates that considerable savings would accrue from following the WHO/UNICEF advice to breastfeed exclusively for six months and continue breastfeeding along with complementary foods for two years or more. Despite relatively high breastfeeding initiation in Germany, neither exclusive breastfeeding nor breastfeeding duration come close to international recommendations. Breastfeeding is mostly regarded as a woman’s personal choice and the government has been slow to engage in breastfeeding promotion, support and research. Some structures in Germany do offer support for breastfeeding women – including the growing number of Baby Friendly Hospital Initiative (BFHI) certified hospitals and a comprehensive maternity leave policy. However, the costs of breastfeeding are mostly borne by the mothers and those for breastfeeding training mostly by the individual health care workers or hospital, while the health insurance companies and society-at-large are profiting from the financial savings from exclusive and long-term breastfeeding. Factors which might improve breastfeeding rates and duration in this country include broad expansion of and financial support for both BFHI hospitals as well as training for the health care personnel who support the mother-infant dyad during the breastfeeding period.     

Rains gone bad, women gone mad: rethinking gender rituals of rebellion and patriarchy

This article reconsiders the argument that 'rituals of rebellion' be seen as women's ritual response to everyday patriarchal structures – an argument originally suggested by Gluckman, but recently evoked by Spencer, the Creiders, and others – in light of recent anthropological theorizing on gender. Using as an example one such women's ritual among the Ihanzu of Tanzania, I show how this particular formulation reduces complex notions of gender and gender practices to unnuanced, monolithic, and all-encompassing gender-systems, both in everyday and ritual realms. This it does, first, by conflating gender ideals with gender behaviours and, second, by ignoring people's conflicting ideas about gender. By problematizing these contradictions, I demonstrate how Ihanzu women's rites are not about rebellion but gender complementarity, played out by women dancers embodying both genders simultaneously. Above all, this case compels us to rethink, fundamentally, 'rituals of rebellion' and 'patriarchy'.     

Picturing Culture: The Photography of Muttappan teyyam between 1920 and Today

Three different appropriations of a 1928 photograph from South India allow insights into German anthropology in the 1920s, contemporary German museum practices, and present-day ritual forms in northern Kerala. Juxtaposing these readings as what Edwards named evidential strategies, power of representation, and re-experiencing demonstrates the possibilities and limits of visual representation. The article contributes to a Picturing Culture debate that considers entrenched visual economies of archived photographs, and opts for an understanding of different aspects of cultural knowledge transported through photographs.